Relentless Health Value

In this episode, Stacey Richter explores how the demands of shareholders influence the actions of publicly traded health insurance companies with guest Wendell Potter. Drawing from Milton Friedman’s assertion that a business’s primary responsibility is to its shareholders, we examine the implications of this philosophy in the healthcare sector. The discussion highlights concerns about fraud allegations among major insurers and the lack of open competition due to market consolidation.  We delve into the concept of the “medical loss ratio,” a key metric for investors, and how it pressures insurers to prioritize profits, often at the expense of patient care. Our guest, Wendell Potter, a former health insurance executive turned advocate for healthcare reform, provides insider insights into these dynamics. He discusses the challenges insurers face in controlling costs, the impact of rising premiums, and the broader consequences for patients and the healthcare system. This episode offers a critical look at the intersection of corporate interests and patient care, shedding light on the systemic issues that arise when profit motives drive healthcare decisions.   All mentioned links can be found in the show notes.  === LINKS === 🔗  Show Notes with all mentioned links:  https://cc-lnk.com/Encore384 ✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙  Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ X   https://twitter.com/relentleshealth/   08:31 What is the medical loss metric? 11:33 “The reality is, insurers have been jacking up premiums … for a long time.” 12:48 “It’s a short-term game.” 15:39 “You’re seeing that these companies are not doing a very good job … of controlling costs because they don’t have the incentive.” 20:19 EP366 with Kevin Schulman, MD. 22:45 How do payers ensure that they’re controlling utilization? 25:53 “It’s death by a thousand cuts.” 31:51 “Just like independent practice physicians are endangered, so are community pharmacists.” 33:17 Who runs our healthcare system?

Dr. Scott Conard, founder of Converging Health, dives into the intricacies of population health management. He highlights that 70% of high-cost patients were previously high-risk yet low-cost, emphasizing the importance of early identification. Discussions revolve around aligning healthcare benefits with community needs for better access and proactive health management. Conard advocates for a holistic view of health, using comprehensive data to create a 'whole person risk score', illustrating that effective management can reduce costs while enhancing patient outcomes.

Stacey Richter dives into the intricacies of healthcare benefit design, spotlighting the challenges posed by moral hazard. She emphasizes the need for balanced benefit plans that encourage high-value care while preventing unintended consequences. Discussions revolve around high deductible health plans and how financial incentives impact patient behavior. Richter questions the binary approach to solutions, urging a nuanced understanding of healthcare utilization and the importance of Pareto optimality in resource allocation.

In this conversation, Chris Crawford, CEO of RxSaveCard, delves into the complex world of GLP-1 medications and the financial dilemmas faced by plan sponsors. He discusses how trying to limit medication volume can paradoxically lead to higher unit costs. Chris explores innovative solutions in the burgeoning cash marketplace, allowing employers to bypass traditional PBM contracts for better pricing. Tune in for insights on navigating pharmacy trends and leveraging alternative strategies to manage healthcare costs effectively.

In this Relentless Health Value episode, Dr. Rushika Fernandopulle discusses with Stacey Richter his four-prong theory of change for transforming the American healthcare system. Key topics include the necessity of new payment models, process innovation, employing a relational technology infrastructure, shifting the cultural mindset towards team-based care, and emphasizing the importance of long-term partnerships. The conversation underscores the urgent need to move away from the current status quo to ensure better health outcomes and affordable care for all Americans. This is one of those episodes where we consider top-line strategic imperatives and key drivers. There was no better person to do this with than Rushika Fernandopulle, MD, who, in case you were unaware, was the founder of Iora Health, an advanced primary care group that was sold to One Medical and then to Amazon.  They discusses his four-prong theory and as Stacey says, "I can’t leave well enough alone, so I plucked one more prong from our conversation and stuck it on the end." For a summary of this 5 prong approach, visit the show notes page where we also list all of the links mentioned in the episode. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP460 ✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙  Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/ ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ X   https://twitter.com/relentleshealth/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social   06:39 How Dr. Rushika Fernandopulle found himself where he is now. 08:06 Dr. Fernandopulle’s conversation with Kenny Cole, MD. 10:33 Why is it important to have new payment models? 12:21 EP453 with Claire Brockbank. 14:50 EP455 with Beau Raymond, MD. 16:19 Why it makes sense to change as quickly as possible. 19:55 How to be proactive and not be reactive and achieve value-based reimbursement for good care. 21:41 Why team-based care is so important for change. 23:37 Why is it important to have a different set of technology tools? 24:38 EP391 with Scott Conard, MD. 25:24 Why changing the culture is important. 27:01 “Getting doctors to do things they don’t like is a waste of time.” 33:22 “Healthcare is local.” 35:31 EP364 with David Muhlestein, PhD, JD. 35:43 Study by Zack Cooper, PhD. 36:53 EP404 with Suhas Gondi, MD, MBA. 39:04 Why long-term partnerships are the only way to make things better.

Bill Sarraille, a Professor of Law and nationally recognized healthcare expert, dives into the complex world of co-pay maximizers and accumulators. He explains how these programs challenge patient affordability and access to medications. The discussion highlights the importance of pricing transparency and the role of Pharmacy Benefit Managers in navigating healthcare costs. Sarraille also raises critical questions about fairness, legality, and the ethical responsibilities within the healthcare system, advocating for clearer communication to protect patients.

In this Inbetweenisode titled 'End of Year Wrap Up and My Personal Charter Encore,' Stacey Richter extends heartfelt thanks to listeners and healthcare workers for their dedication.  She reflects on the challenges of maintaining personal integrity in a profit-driven healthcare system and introduces her personal charter. This charter, focused on ensuring net positive outcomes for patients, acknowledges that achieving transformational change in healthcare requires a collective effort.  Stacey discusses the complexities of balancing ethical decisions, financial constraints, and the broader impact on patient care, urging others to reflect on their own guiding principles. Here's her manifesto which she is now calling her Personal Charter below which she breaks down in this podcast episode: "If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients." === LINKS === 🔗  Show Notes with all mentioned links:  https://cc-lnk.com/INBW41 ✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙  Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe === CONNECT WITH THE RHV TEAM === ✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/ ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ X   https://twitter.com/relentleshealth/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social 06:52 “It’s a zero-sum game.” 07:02 Is the amount of profit fair? 07:13 What is an inescapable fact of the healthcare industry? 07:30 What does the financialization of healthcare mean? 07:55 Why does the self-interest in healthcare matter? 09:54 “It’s basically up to us as individuals to do the right thing.” 13:39 What is the first part of Stacey’s personal charter? 13:54 How does Stacey calculate the net positive of an impact? 14:17 What are two major upsides/downsides that Stacey contemplates? 17:08 Why are incremental change and disruptive change not mutually exclusive? 21:16 “I always try to keep in mind that it will take a village.” 22:55 Why finger pointing is killing innovation in healthcare.

In this insightful discussion, Andreas Mang, Senior Managing Director at Blackstone, shares his expertise in managing healthcare benefits for self-insured employers. He explores how health benefits have morphed into substantial financial considerations for companies, requiring active involvement from C-suites. Topics include the importance of selecting the right brokers, conducting dependent eligibility audits, and fostering transparency in health plans. Mang emphasizes a collaborative approach to navigate the complexities of healthcare costs, ensuring employers are not left at a disadvantage.

Dr. Komal Bajaj, an OB-GYN and chief quality officer for Bronx hospitals, shares groundbreaking insights into addressing healthcare staffing shortages. She discusses the surprising link between cultural alignment and staff retention, emphasizing that healthcare workers are motivated by delivering sustainable, high-quality care. Dr. Bajaj highlights eco-friendly practices and their financial benefits, while also connecting environmental sustainability to improved patient outcomes. The conversation stresses the importance of trust in leadership to reduce burnout and foster a supportive healthcare culture.

Cynthia Fisher, the founder of PatientRightsAdvocate.org, dives into the pressing issue of medical spread pricing, revealing how hidden fees inflate costs for employers and patients alike. She highlights shocking disparities in healthcare claim payments, emphasizing the need for transparency. The discussion also covers recent lawsuits against major players like Cigna, advocating for accountability in healthcare contracts. Fisher argues that price transparency could revolutionize the industry, promoting fairness and potentially lowering costs significantly for all involved.